Dealing with risks in patient care
Quality management
MScN Regina Rosenberg
Qualitätsmanagement/Risikomanagement
Hospitalstrasse 6-10
58099 Hagen
Phone:
02331
-805-761
Mail:
ed.negah-hkk@grebnesor.r
Geschäftsführung, Betriebsleitung (Pflegedirektorin, Ärztlicher Direktor, Klinikmanagement), Qualitätsmanagementbeauftragte
Conference frequency: monatlich
Risk management
Regina Rosenberg
Qualitätsmanagement/Risikomanagement
58018 Hagen
Phone:
02331
-805-761
Mail:
ed.negah-hkk@grebnesor.r
Geschäftsführung, Betriebsleitung (Pflegedirektorin, Ärztlicher Direktor, Klinikmanagement), Qualitätsmanagementbeauftragte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available SOP's, Dienstanweisungen, Rahmenvereinbarungen etc. Risikomatrix (20.05.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Klinisches Notfallmanagement (22.12.2021) |
| RM05 |
Pain management Rahmenvereinbarung Perioperative Schmerztherapie für alle operativen Kliniken (21.11.2022) |
| RM06 |
Fall prophylaxis SOP Sturzmanagement (Prävention von Stürzen, Risikoeinschätzung, Systematische Erfassung aller Stürze, Auswertung aller Sturzereignisse) (01.06.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) SOP Interne Leitlinie Dekubitus (01.06.2021) |
| RM08 |
Regulated handling of custodial measures Leitlinie Fixierung Somatik (19.09.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices SOP Medizintechnik (27.11.2021) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings Sicherstellung wird durch eine Checkliste unterstützt (18.06.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups SOP Verfahren Vermeidung von Eingriffs- und Seitenverwechselungen (18.06.2022) |
| RM18 |
Discharge management SOP's, Dienstanweisungen, Rahmenvereinbarungen etc. Risikomatrix (20.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Austausch von Trennwänden; Anpassung von Pflegepersonalausstattung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.01.2020 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea |